Pathology Education Academic Manpower Survey of 1990: II. Kinetics in the United States (From the Joint Task Force on Pathology Manpower ASCP/CAP/APC)”
ROBERT E. ANDERSON, MD, ROGER D. SMITH, MD, ELLIS S. BENSON, MD, AND DANIEL THOLEN, MS Survey data obtained from chairmen of United States departments of pathology shows a continued shortage of faculty, especially those with the MD or MD/PhD degree. Losses of such faculty by responding departments during the 12 months prior to the survey were distributed as follows: retirement, 40 (15.6% of total); disability/ death, 19 (7.4%); termination, 23 (8.9%); resignation, 172 (69.3%); and other, 3 (1.2%). Resignations were due primarily to decisions to join another university (41.4%) or to enter private practice (42.5%); a small proportion were due to individuals who left academe for a pathology position in government or industry, or left both academe and pathology for another field. Comparison with a similar survey performed in 1984 suggests that the manpower situation in academic pathology is worsening, especially with respect to physician faculty. An assessment of those factors known to influence manpower kinetics suggests that it will continue to deteriorate for the foreseeable future with an adverse impact on all sectors of pathology. HUM PATHOL22:944-947. Copyright G! 1991 by W.B. Saunders Company
This is the most recent of a series of reports concerned with pathology manpower. ‘-I’ These studies, mltil recently, have generally shown a modest discrepancy between supply and demand that resulted in a slight deficit of pathologists based in community hospitals and a moderate shortage of pathologists located in academic medical centers. In the past several years. however, the situation in community practice has begun to change, with an increasing imbalance between supply and demand. This imbalance is due to a growing number of pathologists that are dying, retiring, or otherwise leaving the specialty, accompanied by reduced numbers of persons completing residency training programs in pathology and entering practice. The same factors that adversely impact manpower kinetics in community practice might be expected to
influence academic pathology in comparable fashion. In addition, shortages in community practice have historically resulted in an increase in the movement of pathologists from the academic to the community practice setting, a career change apparently caused by a variety of pressures, including an increase in the discrepancy in salary and related incentives between the two practice settings. Based on the above, it was felt important to reexamine manpower kinetics in academic pathology with specific reference to the impact of the deficit of community pathologists on the academic sector in general and especially on the movement of pathologists between these two practice settings. For this reason, our primary focus will be on pathologists and the pathologist component of academic departments. In a subsequent survey, we plan to perform a similar assessment of all faculty of departments of pathology.
MATERIALS
AND METHODS
The approxh used is summarized in the cxmpanicx~ preIn the cOntext of the present report, it should be emphasized that questions regarding fxulty losses were restricted to full-time faculty and those concerned with projected nerds to full-time faculty equivalents. srt~tation.’
RESULTS Responses were received from 13 1 of 135 (!)7.0%) departments; 128 (94.8%) were usable, and the data were encoded for analysis. Therefore, to extrapolate from survey data to the entire universe of academic pathologists, one must multiply by 1.0547. Table 1 shows the composition of the faculty of U.S. departments of pathology by highest academic degree. Given the objectives of this study, subsequent attention will be confined to the 64.9% of full-time faculty who are pathologists. These individuals, with the MD or MD/PhD degree, will henceforth be referred to as “MD pathologists” to distinguish them from pathology faculty with other types of degrees or with primar) training in a specialty other than patholoa. Table 2 shows the number of MD pathologist faculty that left departments during the year prior to the survey as a function of‘ their reason for leaving. As noted previously, the specific purpose of the present study is to 944
ACADEMIC
MANPOWER
SURVEY,
TABLE 1. Composition of Departments of Pathology by Highest Academic Degree(s) -~
KINETICS (Anderson
TABLE 3.
cxtluate supple and demand with respect to academit pathologists. licnvever, the overall purpose of these ottgoing studies is to determine the pathologist manpower kinetics for the entire discipline. Therefore. it is critical to distinguish among losses to the specialty, transfers rvirhin a specific practice setting, and transplantation from one venue, such as a university, to another. such as a cor~~t~~utritv hospital. For this reason, a specific effort was made to de1 et-tnine the fate of those persons in Table 2 who had resigned during the 12 months prior to the survey. This infortnation is summarized in .I‘ahle 3. Koughlv equal numbers of academic pathologists resigned bortt the reporting departments to join anothet academic department as left for cotnniut~ity practice. The “other” category of resignations involves primaril) ittdividuals leaving departments to assume full-time administrative roles outside of pathology (various types of deans, hospital administrators, directors of research institutes, etc.). The basis for the discrepancy between Tables 2 and 3 in total numbers of resignations is not known. The data were derived frotn different questions and most likely some individuals in the “termination” category of Table 2 were inadvertentI!, included as “resignations” in Table 3. Tables 2 and 3 contain data front the 12 months prior to thly survey; Table -l summarizes the responses of departmental chairmen concerning antic-ipated losses during the year- subsequent to the survey. The figure fix. anticipated deaths/disabilities is derived from the prior 1L’ months’ experience (Table 2). At the lime of the survey. responding chairmen reported a total of SE? (universe: 337) vacant funded positions. Into these open positions, plus those anticipated lo become lracattt during the subsequent jest-. pathology chtirmen planned to attempt to recruit between 402 ;tncl 531 R/II) pathologists. The type of academic pa-
_~
LOSS of MD Pathologists
__--
by Reason
Loss of MD Pathologists Due to Resignation During Prior Year, by Reason _-__
thologisl these chairtnett hoped to IXYruit i$ autntttarized in ‘rahle 5. ‘I‘he top priority t-elates to surgical pathology h); a wide margin. Other key descriptorn itt facxtlty recruitment are that a prospect (I ) be a l~.Cttttologist and (2) have research experience or potential. Of little or no apparent itnportance are gender. nonpathology clinical experience, and tnedical school of origin (Llnited States v foreign). Of intermediate itttportattce ale hoard certificxiott, stthspecialty training, teaching experience, and research grant support. In terms of mechanisms of recruittrtettt of ttew faculty, the following are listed in terms of perceived effectiveness: (1) word of mouth and personal contacts. (2) advertisements in journals and newslettcars, (3) letters to fellow chairmen. and (4) referrals of alutnni of local residency training program. Of equivocal or no apparent value are the CAP Placetnent Bureau. advertisements in newspapers. and unsolicited Ietlers. DISCUSSION 111I !)81, ‘1 survey of academic departments of pathology revealed a fxulty size of 3.489 and 272 open positions. An assessment at that time c)f the career plans of‘ trainees in patltology led us to predict that these and suhseyrttt manpower needs would not lx met by the nutttber~ of trainees in the manpower piprline that had expressed interest in academic medicine. ’ The data r+ pot-ted here support this predictiott. Altlhough the a\eragc nutmt~~t~ of fttll-1 ime facultk prr department has
TABLE 4. TABLE 2.
et al)
During Prior Year, No.
945
Anticipated Loss of MD Pathologists Subsequent Year, by Reason
During
Volume 22, No. 10 (October
HUMAN PATHOLOGY
TABLE 5.
Priority 1 2 3 4 5 6 7 8 9 10
Total
MD Recruitment Priorities During Subsequent 12 Months No. Full-time Equivalent
Area Surgical pathology Research Autopsy Chemistv Blood banking Cytopathology Hematopathology Neuropathology Molecular pathology Other (microbiology, immunolog, pathology, coagulation, etc)
145.0 56.8 51.9 43.8 41.5 34.4 “7.6 22.1 20.5 forensic 87.2 530.8
increased substantially in the interim (25.5 to 28.4), the average number of MD pathologists per department has actually decreased and the number of open positions has increased. These and related comparisons between the data generated by the two surveys are summarized in Table 6. In 1984, pathology chairmen were queried regarding all “open positions,” while in 1990 they were specifically asked about MD pathologists. Review of the 1984 data suggests that 87.3% of the recruitment needs were for MD pathologists; assuming that the 1984 “open positions” were distributed in similar fashion, there were approximately 228 MD pathologist vacancies at that time. On this basis, the vacancy rate among MD pathologists in 1984 was roughly 8.6%; in 1990, this figure had increased to 14.7%. Thus, the manpower situation in academic pathology, at least with respect to MD pathologists, has deteriorated during the interval between the 1984 and 1990 surveys. In looking to the future, unfortunately, the prognosis is also not good. In fact, most indicators suggest a worsening of the current situation; some key observations in support of this unfavorable assessment are as follows: 1. Imposition of the fifth year has diluted the available slots for trainees.s 2. Fewer graduates of United States medical schools are entering PGYI positions in pathology than in the past.’ 3. Continued insufficient numbers of pathology trainees who have expressed interest in an academic career to meet current and projected needs.g Pathology chairmen do not yet appear to recognize that the manpower situation in their departments is deteriorating. Despite their most recent experience, chairmen anticipate an average number (approximately 145) of losses of physician faculty during the 12 months subsequent to the survey. It is unlikely that such will be the case; reference to Table 6 leads us to suspect that losses during 1990-1991 will be comparable to those experienced in 1989-1990, and thus will be roughly 35% higher than chairmen anticipate. Clearly, a worsening imbalance between supply and demand has adverse implications for all of pathology. 946
1991)
Recruitment of medical students to the discipline, difficult at best in recent years, is adversely affected by an undermanned department. For those students who do elect a career in pathology, the vast majority receive their training in academic medical centers.!’ Again, an understaffed faculty cannot be expected to provide an optimal educational experience. Finally, the shortfall of community pathologists is being met in part by siphoning off pathology faculty from academic medical centers. This pool, which apparently consists largely of surgical pathologists, is already in short supply. As it dries up, the manpower situation in community pathology will become even more acute, while patient care needs in academic medical centers may go unmet. Given the above observations, it is not reasonable to expect that current and anticipated vacancies in academic departments can be filled by MD pathologists. The same holds true for community practice, especially when the current stop gap approach of siphoning off pathologists from the academic sector runs dry. Consciously or unconsciously, academic pathology has been adjusting to the discrepancy between supply and demand during the past 5 years by recruiting nonphysicians to the discipline. Many of these persons are PhDs and we suspect that their expertise lies in areas such as medical microbiology, clinical chemistry, molecular biology, and research. In a future survey, we plan to assess the impact of this strategy; informal inputs suggest that it has been highly successful. In the interim, all of pathology would be well served, in our opinion, by the thoughtful discussion and definition of manpower priorities to include (1) increased emphasis on the recruitment of non-MD pathologists to the discipline (this will necessitate an expansion of postdoctoral training opportunities for PhDs interested in one or several aspects of clinical pathology, for example, as well as the reorientation of nonpathologist physicians concerning patient-related priorities in laboratory medicine) and (2) current functions that can be jettisoned without serious adverse impact on students or patients. We are entering a new era in pathology, an era to be characterized by increased patient-related demands requiring progressively ever more sophisticated assessment by pathologists coupled with decreased numbers
TABLE 6.
Select Parameters of Academic Manpower Kinetics: 1984 Versus 1990
I ‘.I81 Parameter Total no. of fxulty Full-rime equivalenr faculty/department MD faculty/department MD faculty (%) Open positions Losses in the prior
I !WO
SW vey
Universe
3.343.0
3.482.0
‘) _~‘, ‘, - 19.5 T!).5 262.0
Surve): 3,640.O
“72.0
Llniversc :~,83O.O
28.4 1x.5 65.0 :‘&+.O*
3ti7.0*
1xti.o*
I sci.o*
lYi.O*
115.0*
12
1110 Anticipated losses (subsequent 12 mo)
L~nhnownLlnknown I JL’.O
* Refers only to the MD pathologist
137.0 component
of the faculty.
ACADEMIC
MANPOWER
SURVEY:
of MD pathologists. How we approach this situation will determine in large measure our future as a discipline. AI a recent retreat of the leadership of organized pathology, some of’ our options were defined and evaluated in very pr’~liminary fashion. Which options hold the greatest promise is not clear at this time. What is clear, however, i,> that the status quo does not constitute a crisis. viable approach to tl le manpower REFERENCIES
947
KINETICS
(Anderson
et al)
ROBERT E. ANDERSON, MD, ROGER D. SMITH, MD, ELLIS S. BENSON, MD, AND DANIEL THOLEN, MS Survey data obtained from chairmen of United States departments of pathology shows a continued shortage of faculty, especially those with the MD or MD/PhD degree. Losses of such faculty by responding departments during the 12 months prior to the survey were distributed as follows: retirement, 40 (15.6% of total); disability/ death, 19 (7.4%); termination, 23 (8.9%); resignation, 172 (69.3%); and other, 3 (1.2%). Resignations were due primarily to decisions to join another university (41.4%) or to enter private practice (42.5%); a small proportion were due to individuals who left academe for a pathology position in government or industry, or left both academe and pathology for another field. Comparison with a similar survey performed in 1984 suggests that the manpower situation in academic pathology is worsening, especially with respect to physician faculty. An assessment of those factors known to influence manpower kinetics suggests that it will continue to deteriorate for the foreseeable future with an adverse impact on all sectors of pathology. HUM PATHOL22:944-947. Copyright G! 1991 by W.B. Saunders Company
This is the most recent of a series of reports concerned with pathology manpower. ‘-I’ These studies, mltil recently, have generally shown a modest discrepancy between supply and demand that resulted in a slight deficit of pathologists based in community hospitals and a moderate shortage of pathologists located in academic medical centers. In the past several years. however, the situation in community practice has begun to change, with an increasing imbalance between supply and demand. This imbalance is due to a growing number of pathologists that are dying, retiring, or otherwise leaving the specialty, accompanied by reduced numbers of persons completing residency training programs in pathology and entering practice. The same factors that adversely impact manpower kinetics in community practice might be expected to
influence academic pathology in comparable fashion. In addition, shortages in community practice have historically resulted in an increase in the movement of pathologists from the academic to the community practice setting, a career change apparently caused by a variety of pressures, including an increase in the discrepancy in salary and related incentives between the two practice settings. Based on the above, it was felt important to reexamine manpower kinetics in academic pathology with specific reference to the impact of the deficit of community pathologists on the academic sector in general and especially on the movement of pathologists between these two practice settings. For this reason, our primary focus will be on pathologists and the pathologist component of academic departments. In a subsequent survey, we plan to perform a similar assessment of all faculty of departments of pathology.
MATERIALS
AND METHODS
The approxh used is summarized in the cxmpanicx~ preIn the cOntext of the present report, it should be emphasized that questions regarding fxulty losses were restricted to full-time faculty and those concerned with projected nerds to full-time faculty equivalents. srt~tation.’
RESULTS Responses were received from 13 1 of 135 (!)7.0%) departments; 128 (94.8%) were usable, and the data were encoded for analysis. Therefore, to extrapolate from survey data to the entire universe of academic pathologists, one must multiply by 1.0547. Table 1 shows the composition of the faculty of U.S. departments of pathology by highest academic degree. Given the objectives of this study, subsequent attention will be confined to the 64.9% of full-time faculty who are pathologists. These individuals, with the MD or MD/PhD degree, will henceforth be referred to as “MD pathologists” to distinguish them from pathology faculty with other types of degrees or with primar) training in a specialty other than patholoa. Table 2 shows the number of MD pathologist faculty that left departments during the year prior to the survey as a function of‘ their reason for leaving. As noted previously, the specific purpose of the present study is to 944
ACADEMIC
MANPOWER
SURVEY,
TABLE 1. Composition of Departments of Pathology by Highest Academic Degree(s) -~
KINETICS (Anderson
TABLE 3.
cxtluate supple and demand with respect to academit pathologists. licnvever, the overall purpose of these ottgoing studies is to determine the pathologist manpower kinetics for the entire discipline. Therefore. it is critical to distinguish among losses to the specialty, transfers rvirhin a specific practice setting, and transplantation from one venue, such as a university, to another. such as a cor~~t~~utritv hospital. For this reason, a specific effort was made to de1 et-tnine the fate of those persons in Table 2 who had resigned during the 12 months prior to the survey. This infortnation is summarized in .I‘ahle 3. Koughlv equal numbers of academic pathologists resigned bortt the reporting departments to join anothet academic department as left for cotnniut~ity practice. The “other” category of resignations involves primaril) ittdividuals leaving departments to assume full-time administrative roles outside of pathology (various types of deans, hospital administrators, directors of research institutes, etc.). The basis for the discrepancy between Tables 2 and 3 in total numbers of resignations is not known. The data were derived frotn different questions and most likely some individuals in the “termination” category of Table 2 were inadvertentI!, included as “resignations” in Table 3. Tables 2 and 3 contain data front the 12 months prior to thly survey; Table -l summarizes the responses of departmental chairmen concerning antic-ipated losses during the year- subsequent to the survey. The figure fix. anticipated deaths/disabilities is derived from the prior 1L’ months’ experience (Table 2). At the lime of the survey. responding chairmen reported a total of SE? (universe: 337) vacant funded positions. Into these open positions, plus those anticipated lo become lracattt during the subsequent jest-. pathology chtirmen planned to attempt to recruit between 402 ;tncl 531 R/II) pathologists. The type of academic pa-
_~
LOSS of MD Pathologists
__--
by Reason
Loss of MD Pathologists Due to Resignation During Prior Year, by Reason _-__
thologisl these chairtnett hoped to IXYruit i$ autntttarized in ‘rahle 5. ‘I‘he top priority t-elates to surgical pathology h); a wide margin. Other key descriptorn itt facxtlty recruitment are that a prospect (I ) be a l~.Cttttologist and (2) have research experience or potential. Of little or no apparent itnportance are gender. nonpathology clinical experience, and tnedical school of origin (Llnited States v foreign). Of intermediate itttportattce ale hoard certificxiott, stthspecialty training, teaching experience, and research grant support. In terms of mechanisms of recruittrtettt of ttew faculty, the following are listed in terms of perceived effectiveness: (1) word of mouth and personal contacts. (2) advertisements in journals and newslettcars, (3) letters to fellow chairmen. and (4) referrals of alutnni of local residency training program. Of equivocal or no apparent value are the CAP Placetnent Bureau. advertisements in newspapers. and unsolicited Ietlers. DISCUSSION 111I !)81, ‘1 survey of academic departments of pathology revealed a fxulty size of 3.489 and 272 open positions. An assessment at that time c)f the career plans of‘ trainees in patltology led us to predict that these and suhseyrttt manpower needs would not lx met by the nutttber~ of trainees in the manpower piprline that had expressed interest in academic medicine. ’ The data r+ pot-ted here support this predictiott. Altlhough the a\eragc nutmt~~t~ of fttll-1 ime facultk prr department has
TABLE 4. TABLE 2.
et al)
During Prior Year, No.
945
Anticipated Loss of MD Pathologists Subsequent Year, by Reason
During
Volume 22, No. 10 (October
HUMAN PATHOLOGY
TABLE 5.
Priority 1 2 3 4 5 6 7 8 9 10
Total
MD Recruitment Priorities During Subsequent 12 Months No. Full-time Equivalent
Area Surgical pathology Research Autopsy Chemistv Blood banking Cytopathology Hematopathology Neuropathology Molecular pathology Other (microbiology, immunolog, pathology, coagulation, etc)
145.0 56.8 51.9 43.8 41.5 34.4 “7.6 22.1 20.5 forensic 87.2 530.8
increased substantially in the interim (25.5 to 28.4), the average number of MD pathologists per department has actually decreased and the number of open positions has increased. These and related comparisons between the data generated by the two surveys are summarized in Table 6. In 1984, pathology chairmen were queried regarding all “open positions,” while in 1990 they were specifically asked about MD pathologists. Review of the 1984 data suggests that 87.3% of the recruitment needs were for MD pathologists; assuming that the 1984 “open positions” were distributed in similar fashion, there were approximately 228 MD pathologist vacancies at that time. On this basis, the vacancy rate among MD pathologists in 1984 was roughly 8.6%; in 1990, this figure had increased to 14.7%. Thus, the manpower situation in academic pathology, at least with respect to MD pathologists, has deteriorated during the interval between the 1984 and 1990 surveys. In looking to the future, unfortunately, the prognosis is also not good. In fact, most indicators suggest a worsening of the current situation; some key observations in support of this unfavorable assessment are as follows: 1. Imposition of the fifth year has diluted the available slots for trainees.s 2. Fewer graduates of United States medical schools are entering PGYI positions in pathology than in the past.’ 3. Continued insufficient numbers of pathology trainees who have expressed interest in an academic career to meet current and projected needs.g Pathology chairmen do not yet appear to recognize that the manpower situation in their departments is deteriorating. Despite their most recent experience, chairmen anticipate an average number (approximately 145) of losses of physician faculty during the 12 months subsequent to the survey. It is unlikely that such will be the case; reference to Table 6 leads us to suspect that losses during 1990-1991 will be comparable to those experienced in 1989-1990, and thus will be roughly 35% higher than chairmen anticipate. Clearly, a worsening imbalance between supply and demand has adverse implications for all of pathology. 946
1991)
Recruitment of medical students to the discipline, difficult at best in recent years, is adversely affected by an undermanned department. For those students who do elect a career in pathology, the vast majority receive their training in academic medical centers.!’ Again, an understaffed faculty cannot be expected to provide an optimal educational experience. Finally, the shortfall of community pathologists is being met in part by siphoning off pathology faculty from academic medical centers. This pool, which apparently consists largely of surgical pathologists, is already in short supply. As it dries up, the manpower situation in community pathology will become even more acute, while patient care needs in academic medical centers may go unmet. Given the above observations, it is not reasonable to expect that current and anticipated vacancies in academic departments can be filled by MD pathologists. The same holds true for community practice, especially when the current stop gap approach of siphoning off pathologists from the academic sector runs dry. Consciously or unconsciously, academic pathology has been adjusting to the discrepancy between supply and demand during the past 5 years by recruiting nonphysicians to the discipline. Many of these persons are PhDs and we suspect that their expertise lies in areas such as medical microbiology, clinical chemistry, molecular biology, and research. In a future survey, we plan to assess the impact of this strategy; informal inputs suggest that it has been highly successful. In the interim, all of pathology would be well served, in our opinion, by the thoughtful discussion and definition of manpower priorities to include (1) increased emphasis on the recruitment of non-MD pathologists to the discipline (this will necessitate an expansion of postdoctoral training opportunities for PhDs interested in one or several aspects of clinical pathology, for example, as well as the reorientation of nonpathologist physicians concerning patient-related priorities in laboratory medicine) and (2) current functions that can be jettisoned without serious adverse impact on students or patients. We are entering a new era in pathology, an era to be characterized by increased patient-related demands requiring progressively ever more sophisticated assessment by pathologists coupled with decreased numbers
TABLE 6.
Select Parameters of Academic Manpower Kinetics: 1984 Versus 1990
I ‘.I81 Parameter Total no. of fxulty Full-rime equivalenr faculty/department MD faculty/department MD faculty (%) Open positions Losses in the prior
I !WO
SW vey
Universe
3.343.0
3.482.0
‘) _~‘, ‘, - 19.5 T!).5 262.0
Surve): 3,640.O
“72.0
Llniversc :~,83O.O
28.4 1x.5 65.0 :‘&+.O*
3ti7.0*
1xti.o*
I sci.o*
lYi.O*
115.0*
12
1110 Anticipated losses (subsequent 12 mo)
L~nhnownLlnknown I JL’.O
* Refers only to the MD pathologist
137.0 component
of the faculty.
ACADEMIC
MANPOWER
SURVEY:
of MD pathologists. How we approach this situation will determine in large measure our future as a discipline. AI a recent retreat of the leadership of organized pathology, some of’ our options were defined and evaluated in very pr’~liminary fashion. Which options hold the greatest promise is not clear at this time. What is clear, however, i,> that the status quo does not constitute a crisis. viable approach to tl le manpower REFERENCIES
947
KINETICS
(Anderson
et al)
